Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Columbia Manor Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to administer medications as ordered and did not document reasons for holding multiple medications for a cognitively intact resident with several chronic conditions, including hypertension, renal failure, hyperlipidemia, and prior stroke. Review of physician orders and MARs over several months showed numerous instances where daily and BID medications such as antihypertensives, anticoagulants, supplements, pain medication, and GI agents were marked as held without documented justification or new MD orders. A CMT reported that medications were sometimes held for low BP, loose stools, or the resident not feeling well, believed that MD orders were not always needed to hold certain drugs even without parameters, did not recall notifying the MD, and did not document reasons for the holds, contrary to facility policy requiring medications to be given as prescribed and concerns to be communicated to the prescriber.
A resident who was cognitively intact with anxiety and depression, and prescribed Ativan but not Oxycodone, was given another resident’s Oxycodone by a CMT, contrary to facility policy requiring verification of the right resident and medication before administration. The resident reported receiving two small white pills, feeling unwell, and later being told that 10 mg of Oxycodone had been administered instead of Ativan. Although facility policy required that medication errors be documented in the chart, reported, and investigated, record review showed no documentation of the error, no investigation records, and no notation in the resident’s progress notes for the date of the incident, despite the administrator’s expectation that such information be recorded.
Staff failed to follow facility policy requiring prompt notification of a change in condition and treatment refusals. A resident on hospice for a short stay was found with a lump on the forehead of unknown cause, which an LPN assessed but did not report to a physician or the resident’s representative. On a separate occasion, the same resident refused all scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa, without any documented notification to the attending physician, hospice physician, hospice staff, or the resident’s representative. In subsequent interviews, the LPN acknowledged forgetting to notify anyone, and the administrator, resident representative, attending physician, and hospice physician all stated they had not been informed and would have expected notification.
Facility staff did not report an allegation of bruises and injuries of unknown origin for a resident to DHSS within the required 24-hour timeframe, as required by the facility’s abuse investigation and reporting policy. A resident’s representative twice informed the DON and the administrator that the resident returned home with a lump on the forehead, a laceration above the ear, bruising under the arm and on the side, and genital excoriation, without specifically alleging abuse or neglect. Despite these reports, the allegation of injuries of unknown origin was not submitted to DHSS until more than 48 hours after it was first reported to facility staff.
Staff failed to complete and document required skin assessments for a hospice patient admitted for a short stay with Parkinsonism, essential tremors, and A-fib. An LPN documented a lump on the patient’s forehead, but no follow-up skin assessment was recorded in the EMR after this change or prior to discharge, despite facility expectations and standard nursing protocol for head-to-toe and skin assessments with new skin changes and before discharge. After the patient returned home, the representative reported additional skin concerns, including a forehead lump, laceration above the ear, bruising to the side/underarm, and genital excoriation, none of which were documented by facility staff.
Facility staff did not notify the attending physician after a cognitively impaired resident, who required extensive assistance, fell in the shower and sustained a head injury. The DON responded, initiated neurological checks, and relied on hospice staff to notify the family and hospice nurse practitioner, but did not follow policy requiring physician notification. The care plan lacked documentation of fall risk assessment or interventions, and nurse's notes did not show physician notification.
Facility staff did not provide a required discharge notice for a resident transferred to the hospital and subsequently refused to allow the resident to return when the hospital determined admission was unnecessary, citing inability to meet care needs. Documentation and interviews confirmed the absence of a discharge notice and noncompliance with facility policy.
Wet dishes were stacked and stored before air drying, and wet plate covers and trays were later used during meal service. Surveyors observed wet plates, food service pans, trays, and plate covers stacked in the dishwashing area and service station. The CDM said he/she washed the plates that morning and did not realize they were still wet when stacked, and the administrator stated washed dishes should be air dried before being stacked into storage or used.
Facility staff failed to keep care plans complete and accurate for several residents. One resident with a Full Code order, two residents with DNR orders, and another resident with prior PEG tube and antibiotic-related documentation had care plans that did not match current orders or condition. The record also showed outdated references to PEG tube care, EBP, and Amoxicillin even though staff and the resident confirmed those items were no longer current.
Infection control and hand hygiene failures occurred when staff cared for two residents with COVID-19 and during wound treatment for two residents. A CNA entered COVID-19 positive rooms wearing a gown, gloves, and respirator but no eye protection, and stated eye wear was not available. An LPN also failed to perform proper hand hygiene and glove changes during wound care, using soiled gloves while moving between dirty and clean tasks and handling wound supplies and personal items.
Call-light system and pager use failures affected three cognitively intact residents. Facility logs showed repeated call-light response times over 30 minutes, including waits over an hour and one over two hours. Observations found the centralized monitor was not audible and CNAs were not wearing pagers, with staff stating they checked the desk monitor instead. Residents reported long waits for help with toileting and remaining in urine or waste while waiting for staff.
Staff failed to provide access to the emergency medication kit (E-Kit) for qualified personnel, resulting in multiple newly admitted residents not receiving their prescribed evening and bedtime medications. The facility's policy lacked guidance on E-Kit use, and staff did not document missed doses in progress notes. Interviews revealed confusion and lack of awareness among leadership regarding responsibility for granting E-Kit access.
Staff did not implement Enhanced Barrier Precautions due to lack of education, communication, and absence of a facility policy, resulting in two residents with wounds not having appropriate PPE available in their rooms and staff providing care without required gowns or gloves.
The facility failed to implement complete water system management policies, risking Legionella growth. Observations showed overdue ice machine filter changes and lack of air gap in drainage. The maintenance director was unaware of necessary procedures, and the administrator relied on their expertise without verification.
Facility staff failed to maintain a clean and homelike environment, with observations of unclean and damaged areas in resident rooms, including dark substance buildup on floor grout, gouges on bathroom floors, and rusted door frames. Interviews revealed lapses in reporting and addressing these issues, with maintenance requiring corporate approval for repairs.
The facility failed to develop comprehensive person-centered care plans for three residents, missing critical interventions for dementia care, behavior management, and activity preferences. Despite having a policy for care planning, the plans did not reflect the residents' medical histories or preferences. Staff interviews confirmed the need for care plans to include specific behaviors and updates, which were not present.
Facility staff failed to document weights for multiple residents and did not follow dietician recommendations for a resident with a diabetic foot ulcer. Despite orders for regular weight checks, records showed missing documentation over several months. Interviews revealed a lack of awareness and follow-up on these issues, contributing to the deficiency.
Two residents were unsafely propelled in wheelchairs without footrests, leading to a deficiency in accident hazard prevention. One resident with Alzheimer's and Parkinson's had their feet contacting the floor, while another with multiple conditions had their feet gliding across the floor. Staff admitted to not using footrests due to oversight and acknowledged the importance of using them to prevent injuries.
The facility failed to obtain informed consent for the use of bed side rails for six residents, despite a policy requiring such consent. Observations showed residents using side rails without documented consent in their medical records. Interviews with staff, including the MDS Coordinator and DON, revealed a lack of awareness about the consent requirement, leading to this deficiency.
The facility failed to ensure that ten nurse aides completed their CNA training within the required four months of employment. Despite the facility's policy, logistical challenges such as distant testing centers and filled local sites delayed the process. The DON and administrator acknowledged the issue, and nurse aides expressed frustration over the delays.
Facility staff failed to monitor and document the effectiveness and side effects of psychotropic and antipsychotic medications for several residents, leading to deficiencies in care. Residents were prescribed multiple medications without appropriate diagnoses or documentation of monitoring. Interviews with staff revealed a lack of adherence to facility policies on medication use and monitoring.
The facility did not comply with regulations by charging two NAs for CNA training and certification expenses through paycheck deductions. The Missouri Department of Health and Senior Services form showed a charge of $850.00 for training. Interviews revealed that NAs were informed of this requirement upon application, and one NA had not been reimbursed. The DON and administrator confirmed the practice, citing new ownership policies.
Facility staff failed to document the administration or refusal of the pneumococcal vaccine for three residents, despite having a policy requiring such documentation. The DON and care plan nurse cited challenges in maintaining accurate records, including difficulties in obtaining information from hospitals during the admission process.
Facility staff failed to consistently document the code status for two residents, leading to discrepancies between Full Code and DNR statuses. One resident had conflicting documentation between the nurse's notes, Physician Order Sheet, and an OHDNR form. Another resident's records showed inconsistencies between the Admission MDS, baseline care plan, and comprehensive care plan. Staff interviews revealed a lack of coordination between nursing and social services in verifying and updating code statuses.
A resident requiring hemodialysis did not receive proper care and monitoring before and after treatments due to facility staff's failure to conduct ongoing assessments and communicate with the dialysis clinic. The facility's policy lacked guidance on necessary assessments, and the resident's medical records did not document hemodialysis treatments. Interviews with staff revealed confusion and oversight in managing the resident's care.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
Facility staff failed to administer medications as ordered and failed to document reasons for holding medications for one cognitively intact resident with multiple chronic conditions, including hypertension, renal failure, hyperlipidemia, and a history of stroke. The resident’s physician orders in January included multiple daily and BID medications such as amlodipine, atorvastatin, cranberry, melatonin, pantoprazole, potassium chloride, spironolactone, thiamine, vitamin D3, cetirizine, apixaban (Eliquis), house shakes, gabapentin, and lactulose. Review of the January MAR showed numerous instances where these medications were marked as held on specific dates without any documented reason or corresponding physician orders to hold them. Similar issues continued in February, when gabapentin and spironolactone were held on several dates without documentation of the reason or evidence of new physician orders, and in March, when spironolactone and ondansetron were held without documented justification or physician authorization. During an interview, the CMT who documented the held medications stated they did not recall why the hold code was used multiple times for the resident and explained that, in practice, medications might be held if blood pressure was low, if residents had loose stools, or if they were not feeling well. The CMT further stated that whether the physician needed to be contacted depended on the reason for holding the medication, and that they believed they did not need orders to hold blood pressure medications or stool softeners even when no parameters were included in the original orders. The CMT reported not recalling notifying the physician about holding medications for this resident and acknowledged not documenting the reasons for holding them. The facility’s medication administration policy required medications to be administered as prescribed and for staff to contact the prescriber or physician if a dosage was believed to be inappropriate or associated with adverse consequences, but the records and interviews showed this process was not followed for this resident. Complaint #2799285
Significant Medication Error and Lack of Documentation After Wrong Drug Administered
Penalty
Summary
Facility staff failed to ensure residents remained free from significant medication errors when a Certified Medication Technician (CMT) administered one resident’s prescribed medication to another resident. The facility’s Administering Medications policy, revised April 2019, required staff to verify resident identity using methods such as checking identification bands, photographs, and, if necessary, confirming identity with other personnel, and to check the medication label three times to ensure the right resident, medication, dose, time, and route. Despite these requirements, CMT A reported giving one resident another resident’s Oxycodone instead of the ordered Ativan. The resident’s physician order sheet did not contain any order for Oxycodone, and the resident was assessed as cognitively intact with diagnoses of anxiety and depression. The resident reported receiving two small white pills from CMT A, then feeling “really funny,” and later being informed by a nurse that 10 mg of Oxycodone had been given instead of Ativan. The facility’s policy also required that medication errors be documented, reported, and reviewed by the QUAPI committee, and that such errors be documented in the resident’s chart with details of what happened, when it happened, corrective actions taken, and when the family and physician were notified, as well as monitoring and documentation of adverse reactions. However, review of the resident’s progress notes and facility-provided records for the date of the incident showed no documentation of a medication error or any facility investigation related to the error. The administrator stated there had been one medication error for this resident but did not know the details due to being on leave and acknowledged there was no proof of what the prior management nurse had done regarding the investigation. The resident reported that staff called the physician and monitored blood pressure after the error and that CMT A apologized, but the lack of corresponding documentation and investigation records demonstrated the facility’s failure to follow its own medication administration and error-reporting policies.
Failure to Notify Physician and Representative of Change in Condition and Medication Refusals
Penalty
Summary
Facility staff failed to notify the physician and resident representative of changes in a resident’s condition and treatment status as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised 02/2021, directed staff to promptly notify the resident, attending physician, and resident representative of changes in medical or mental condition, discovery of injuries of unknown source, significant changes in condition, and refusal of treatment or medications two or more consecutive times. For one resident admitted from home with hospice services for a planned five-day stay, staff documented an incident in which a CNA alerted an LPN to a lump on the resident’s left forehead. The LPN assessed the resident as alert and oriented, with a lump present, no discoloration, no pain or discomfort, and no other identified injuries. The incident report and medical record contained no documentation that the physician or resident representative were notified of this potential injury of unknown source. The same resident’s POS listed multiple scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa. The MAR showed that on one day, the resident refused all of these scheduled medications. There was no documentation that the physician, hospice physician/staff, or resident representative were notified of the medication refusals. In interviews, the administrator stated staff could not determine the cause of the forehead lump and acknowledged an expectation that the nurse notify the on-call physician, hospice physician, and resident representative of both the lump and the medication refusals. The LPN involved stated he/she did not know what caused the lump and admitted he/she should have notified the physician and resident representative but became busy and forgot. The resident representative, attending physician, and hospice physician each reported they had not been notified of the lump or the medication refusals and stated they would have expected such notification.
Failure to Timely Report Injuries of Unknown Origin to DHSS
Penalty
Summary
Facility staff failed to report an allegation of bruises and injuries of unknown origin for one resident to the Department of Health and Senior Services (DHSS) within the required 24-hour timeframe. The facility’s abuse investigation and reporting policy, revised 07/2017, required that alleged violations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 24 hours if the alleged violation did not involve abuse with serious bodily injury. The resident, who had been admitted from home for a planned five-day stay and then discharged back home, had a documented resident representative. The representative first reported to the DON that, after returning home, the resident had an abrasion to the left side, a laceration approximately 0.5 inches above the left ear, bruising under the left armpit, and a lump to the back, but did not specify abuse or neglect or accuse anyone. The next day, the resident representative made a second report to the administrator, again describing a lump to the left forehead, a laceration above the left ear, bruising to the left side/underarm, and excoriation to the genitals. Despite these reports, the facility did not notify DHSS within 24 hours of the initial allegation of bruises and injuries of unknown origin. The DON acknowledged that, based on the information received from the resident representative and staff interviews, DHSS should have been notified within 24 hours of the initial report. The administrator also acknowledged that staff should have made an initial report to DHSS within the required timeframe but did not do so, and the DHSS complaint/facility self-report database contained no report from the facility until more than 48 hours after the allegations were first reported to facility staff.
Failure to Complete and Document Required Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of quality by not completing and documenting required skin assessments for a resident who developed a lump on the forehead and was later discharged. The resident, admitted from home for a planned five-day stay with hospice services, had diagnoses including Parkinsonism unspecified, essential tremors, and atrial fibrillation. An incident report documented by an LPN noted a lump on the resident’s left forehead with no discoloration, no pain, and no identified injuries. However, the electronic medical record from the date of the incident through discharge contained no documentation that a skin assessment was completed following the identification of the lump. Additionally, there was no documented skin assessment prior to the resident’s planned discharge, despite interviews indicating that it was standard protocol and expectation for nurses to complete a head-to-toe and skin assessment on admission, with any identified skin changes, and prior to discharge. The DON, an LPN responsible for the discharge assessment, the administrator, and the LPN who identified the lump each acknowledged in interviews that a skin assessment should have been completed and documented in these circumstances. After discharge, the resident’s representative reported multiple skin issues, including a lump on the forehead, a laceration above the left ear, bruising to the left side/underarm, and genital excoriation, which were not documented in the facility’s records.
Failure to Notify Physician After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to notify the attending physician following a significant change in condition for a resident who experienced a fall with a head injury. According to the facility's policy, staff are required to promptly notify the resident, their attending physician, and the resident's representative of any changes in medical or mental condition, including accidents or incidents. In this case, a cognitively impaired resident, who required extensive assistance with bathing and was being assisted by a hospice aide, fell in the shower room, resulting in a raised, purple area above the right eye. The DON was notified and responded to the incident, initiated neurological checks, and assessed the resident, but did not notify the attending physician as required by policy. Interviews revealed that the DON relied on the hospice nurse to notify the family and hospice nurse practitioner, and believed that hospice staff would determine the next steps for a resident on hospice care. However, both the administrator and corporate nurse confirmed that facility staff are responsible for notifying the attending physician in the event of a fall, especially one involving a head injury. The care plan for the resident did not document fall risk assessment or interventions for falls, and the nurse's notes lacked documentation of physician notification after the incident.
Failure to Provide Discharge Notice and Allow Resident Return After Hospital Transfer
Penalty
Summary
Facility staff failed to provide a required discharge notice for a resident who was transferred to the hospital. The resident was initially admitted and then transferred to the hospital due to fluid leakage from the skin. Documentation shows that after the hospital determined there was no reason to admit the resident and requested the facility to arrange for the resident's return, facility staff refused to allow the resident to return, stating they could not meet the resident's care needs. The facility's policy requires notification of the resident's physician, the receiving facility, preparation of a transfer form, and notification of the resident's representative or family, but there was no evidence that a 30-day discharge or emergency discharge notice was provided in this case. Interviews with the Social Service Director and the administrator confirmed that the decision not to allow the resident to return was made by the administrator, and that no discharge notice was issued because staff were focused on transferring the resident and did not anticipate the resident's return. Review of the electronic medical record confirmed the absence of the required discharge notice, indicating noncompliance with discharge procedures and regulatory requirements.
Wet Dishes Used Before Air Drying
Penalty
Summary
Facility staff failed to allow sanitized dishes to air dry before stacking them in storage and using them for meal service. Review of the facility policy titled Cleaning Dishes/Dish Machine, dated 2021, showed washed dishes were to be air dried on dish racks, inspected for cleanliness and dryness before being put away, and not nested unless completely dry. On 08/05/25 at 10:10 A.M., surveyors observed six wet plates stacked together on a service cart in the mechanical dishwashing area. During interview at that time, the CDM stated he/she had washed the plates that morning and said washed dishes should be air dried before being put away, but he/she did not realize they were still wet when stacked on the cart. Later that morning, surveyors observed nine wet metal food service pans, 12 wet plastic service trays, and 15 wet plastic plate covers stacked together in the service station. During lunch meal service, the CDM used the wet stacked plate covers and trays to serve food to residents. The administrator stated washed dishes should be air dried before they are stacked into storage or used, and that the person washing the dishes is responsible for ensuring they are dry before putting them away.
Incomplete and inaccurate care plans for code status and discontinued treatments
Penalty
Summary
Facility staff failed to ensure complete, accurate, and individualized care plans for four sampled residents. The facility policy stated the interdisciplinary team develops and implements comprehensive, person-centered care plans that incorporate identified problem areas, risk factors, and current standards of practice, and that care plans are revised when a resident’s condition changes. Review of the records showed that Resident #3 was cognitively impaired and had a physician order for Full Code, but the care plan did not include guidance or direction for advanced care planning or the Full Code order. Resident #7 was cognitively impaired and had a DNR order signed by the resident and/or family and physician, but the care plan did not include guidance or direction for advanced care planning or the DNR order. Resident #32 had diagnoses including aphasia, stroke, seizure disorder, and malnutrition, and was assessed as cognitively intact. The quarterly MDS did not include the PEG tube, therapeutic diet, or antibiotics, yet the care plan stated the resident was on EBP related to a PEG tube and on Amoxicillin for prophylaxis for possible aspiration pneumonia. The POS showed no orders for PEG tube management, therapeutic diet, EBP, or Amoxicillin, and nursing notes documented the resident came out with the feeding tube site open holding the gastric tubing in his/her hands; the resident later stated the PEG tube was no longer present, and staff confirmed the Amoxicillin had been discontinued. Resident #34 was cognitively impaired and had a DNR order, but the care plan did not include guidance or direction for advanced care planning or the DNR order.
Infection Control and Hand Hygiene Failures During COVID-19 Care and Wound Treatment
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not follow infection control protocols for residents with COVID-19 and did not perform appropriate hand hygiene during wound care. The facility’s COVID-19 policy required symptomatic residents suspected or confirmed with COVID-19 to remain in their rooms and be cared for by staff using a respirator, eye protection, gloves, and a gown. CDC guidance reviewed by surveyors also stated that health care providers entering the room of a patient with suspected or confirmed SARS-CoV-2 infection should use standard precautions and wear an N95 or higher respirator, gown, gloves, and eye protection. Resident #10 and Resident #24 were both cognitively intact and had tested positive for COVID-19 on 07/28/25. Both residents told surveyors that staff did not wear eye protection during their care. During observation on 08/05/25, CNA F entered each resident’s room wearing a gown, gloves, and respirator mask, but did not wear eye protection. CNA F stated that eye wear was not available and that he/she used what PPE was available. RN G, the DON, and the administrator each acknowledged that staff caring for COVID-19 positive residents should wear eye protection, and the DON and administrator stated that face shields or goggles had been ordered but staff were not wearing them. The facility also failed to follow hand hygiene and wound care procedures for Resident #38 and Resident #41. The facility’s hand hygiene and wound care policies required handwashing or hand hygiene before and after wound care tasks, including when moving from a dirty site to a clean site and after removing gloves. During wound care observations, LPN A touched Resident #38’s wound, applied ointment and a dressing, and did not change gloves or perform hand hygiene when moving from dirty to clean care. For Resident #41, LPN A used the same soiled gloves while removing dressings, touching clean dressing supplies, applying treatments, handling personal items, and moving between wound sites and clean tasks without washing hands. LPN A stated that hand hygiene and glove changes should occur when moving from dirty to clean sites and said he/she got nervous and did not perform good hand hygiene during care. The DON and administrator stated that staff were expected to follow the facility’s hand hygiene and wound care policies.
Call-Light System and Pager Use Failures
Penalty
Summary
The facility failed to ensure a working call system was available in resident bathrooms and bathing areas and failed to ensure direct care staff consistently carried and used wireless nurse call pagers when call-light response times exceeded 30 minutes for three sampled residents. The facility policy titled, "Answering the Call Light," dated March 2021, stated to be sure the light is plugged in and functioning at all times, but it did not include direction for paging devices to audibly alert staff of a resident's call for assistance. The facility census was 38.1. Review of the facility's Past Call's logs showed multiple call-light response times over 30 minutes on 08/02/25, 08/03/25, and 08/04/25, including several responses over one hour and one response over two hours. During observation on 08/05/25, the centralized call light monitor for one room was altered and did not have an audible sound, and staff passing by could not hear pager noise. The same day, CNA D was observed without a pager and stated he/she forgot to get one and usually just walked up the hall to check the monitor at the desk. CNA F was also observed without a pager and stated he/she did not wear one and did not know anything about the pagers, instead walking to the desk to check for call lights. Resident #3, Resident #10, and Resident #24 were assessed as cognitively intact on their MDS assessments. During interviews, Resident #3 said it could take one to two hours before staff answered the call light and that he/she had to lay in his/her waste for long periods of time. Resident #10 said call light wait times were long and that he/she could not hold urine and needed staff help to stay clean. Resident #24 said he/she wore a depend and, when staff took too long, he/she had to sit in urine and sometimes waited up to an hour to an hour and a half for help. The DON stated nursing staff were expected to carry a pager and that a 20-minute wait time was unacceptable, while the Administrator stated staff were not wearing pagers, the call lights did alarm at the nurse station monitor, and he/she was unaware call-light times were longer than 20 minutes.
Failure to Provide E-Kit Access Results in Missed Medication Administration
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not ensuring that qualified staff had access to the facility's emergency medication kit (E-Kit), resulting in the failure to administer prescribed medications to three newly admitted residents. The facility's Medication Pass Policy did not include guidance on administering medications from the E-Kit, and staff did not document missed medication administration in the residents' progress notes as required. For each of the three residents, review of their Medication Administration Records (MARs) showed that evening and bedtime doses of multiple prescribed medications were not given on their admission or re-admission dates, with staff noting only to 'see progress notes,' which lacked any documentation of the missed doses. The residents affected included one with high cholesterol and depression, another with hypertension and depression, and a third with cognitive impairment, cerebral vascular accident, and hemiplegia. Each had physician orders for multiple medications, including antihypertensives, muscle relaxants, antidepressants, anticoagulants, and cholesterol-lowering agents. The medications were not administered as ordered due to staff not having access to the E-Kit, and there was no documentation in the progress notes to explain or address the missed doses. Interviews with facility staff revealed that the process for granting E-Kit access was unclear and not consistently implemented. The DON, who was new to the facility, was unaware of who was responsible for setting up E-Kit access. A Certified Medication Technician (CMT) reported not having access since starting employment, and the administrator was unaware that some CMTs lacked access. The President of Clinical Operations confirmed that the DON and pharmacist could set up E-Kit access but was not aware that staff had been unable to administer medications due to lack of access.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) as required, resulting in a lack of staff education and communication regarding which residents required EBP. The facility did not have an EBP policy in place, and staff were not consistently informed about the need to use personal protective equipment (PPE) during high-contact care activities for residents with wounds or indwelling medical devices. Observations revealed that PPE, such as gowns and gloves, was not available in close proximity to the rooms of two residents with wounds, and signage indicating required PPE was absent. Staff interviews confirmed that some CNAs were unaware of EBP requirements and had not received adequate communication or training on the policy. For one resident with multiple unstageable pressure ulcers and physician orders for wound care, staff entered the room to provide incontinence care without donning gowns, and no PPE cart was present outside the room. Another resident developed a new wound, and staff again provided care without using gowns or having PPE readily accessible. Multiple staff members reported confusion about EBP, citing a lack of clear communication and insufficient PPE availability. The facility's census at the time was 37 residents.
Deficiency in Water System Management for Legionella Prevention
Penalty
Summary
The facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water systems, which are crucial for inhibiting the growth of waterborne pathogens such as Legionella. This deficiency was identified through observation, interview, and record review, revealing that the facility's water management program lacked documentation of monthly water heater flushing, a critical control measure. The facility census was 37 with a capacity of 52, indicating a significant number of residents potentially at risk. During the Life Safety Code tour, it was observed that the facility contained two ice machines for resident use, one of which had a drainage tube without an air gap, a necessary feature to prevent contamination. Additionally, the ice machine filter was overdue for replacement, as it was last changed in December 2022, contrary to the manufacturer's instructions to replace it every six months. The maintenance director admitted to not being aware of the requirement for an air gap in the ice machine drain and was unsure why the filter had not been changed. Interviews with the maintenance director and the administrator revealed a lack of awareness and understanding of the necessary procedures for maintaining the water systems. The maintenance director was unaware of the need to flush water heater tanks as a Legionella control measure and maintained water temperatures between 105 and 120 degrees Fahrenheit, which may not be sufficient to inhibit bacterial growth. The administrator relied on the maintenance director for expertise but was not sure if inspections included checking for an air gap in the ice machine drain or if the water heater flush was being conducted as required.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by multiple observations of unclean and damaged areas in resident rooms. Observations on two separate days revealed a buildup of a dark substance on the floor tile grout lines in several occupied rooms, gouges on bathroom floors, and dark dried smears on bathroom wall tiles around toilets. Additionally, there were large gouges and rough edges on bathroom doors, rusted bathroom door frames, and cracked sink countertops with rough edges. Interviews with facility staff, including CNAs, the Maintenance Director, and the Director of Nursing, indicated that while staff are expected to report damaged areas to the Maintenance Director and housekeeping is responsible for cleaning, there were lapses in addressing these issues. The Maintenance Director acknowledged awareness of some damages but cited the need for corporate office approval for repair expenses. Housekeeping staff stated that resident rooms are cleaned daily, and issues like smears should be addressed immediately, yet the observations showed otherwise.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for three residents out of a sample of ten, despite having a policy in place since December 2016 that outlines the requirements for such care plans. The policy mandates that care plans should be derived from a thorough analysis of comprehensive assessments, include measurable objectives and timeframes, and reflect the resident's personal and cultural preferences. However, the care plans for the residents in question did not meet these standards. Resident #9's care plan, dated January 25, 2024, lacked interventions for dementia care, behavior management, pain management, and risk of bleeding associated with anticoagulant and antiplatelet use, despite the resident's complex medical history, including a stroke, dementia, and anxiety, and a comprehensive medication regimen. The MDS Coordinator acknowledged the absence of these interventions, citing the resident's lack of behaviors and signs of dementia as reasons for their exclusion. Resident #33's care plan did not address the resident's social, cognitive, or activity needs, despite severe cognitive impairment and a history of serious medical conditions. Similarly, Resident #143's care plan failed to include activity preferences, smoking safety, and fall interventions, even though the resident had severe cognitive impairment, a history of falls, and specific activity preferences. Interviews with facility staff, including the MDS Coordinator, RN, and DON, revealed a consensus that care plans should include specific behaviors, triggers from MDS assessments, and updates with changes in resident conditions, but these were not reflected in the care plans reviewed.
Failure to Document Weights and Follow Dietician Recommendations
Penalty
Summary
The facility staff failed to meet professional standards of care by not obtaining and documenting weights for five residents and not following up on dietician recommendations for one resident. The facility's policy required weights to be measured on admission and monthly, with documentation in the resident's record. However, the records for several residents showed missing weight documentation over several months, indicating a failure to adhere to the policy. Resident #1, who was cognitively intact and had diagnoses including anemia and kidney disease, had a physician's order to be weighed monthly, but no weights were documented from January to May 2024. Similarly, Resident #12, with diagnoses such as thyroid disorder and dementia, was supposed to be weighed weekly after admission and then monthly, but the records lacked documentation for several weeks and months. Resident #17, with severe cognitive impairment and Alzheimer's, had no documented weights for April or May 2024, and Resident #33, with severe cognitive impairment and multiple diagnoses, also lacked weight documentation for three months. Resident #142, who had a diabetic foot ulcer and was admitted in April 2024, was not weighed as ordered after readmission in May 2024. Additionally, dietician recommendations for this resident, including supplements and monitoring, were not followed up on. Interviews with the DON, dietician, LPN, and NA revealed a lack of awareness and follow-up on weight documentation and dietician recommendations, contributing to the deficiency.
Deficiency in Safe Wheelchair Propulsion
Penalty
Summary
Facility staff failed to safely propel two residents in wheelchairs, leading to a deficiency in ensuring a safe environment free from accident hazards. The facility did not have a specific wheelchair propulsion policy. Resident #17, who has Alzheimer's and Parkinson's disease, was observed being propelled by a CNA without foot pedals, causing the resident's feet to make contact with the floor. The CNA acknowledged the oversight, citing the resident's leg contractures as the reason for not using footrests. Similarly, Resident #8, who has a history of stroke, dementia, aphasia, seizures, depression, and respiratory failure, was also propelled by a CNA without footrests, resulting in the resident's feet gliding across the floor. The CNA admitted forgetting to attach the footrests as they were not with the wheelchair. Interviews with the LPN, DON, and the administrator confirmed that staff are educated on the importance of using footrests to prevent potential injuries, and they acknowledged their responsibility for resident safety.
Failure to Obtain Informed Consent for Bed Side Rails
Penalty
Summary
The facility staff failed to obtain informed consent for the use of bed side rails for six residents, despite the facility's policy requiring such consent. The policy, dated December 2016, mandates that staff obtain consent from the resident or their legal representative before using side rails. Observations and interviews revealed that residents were using side rails without documented consent in their medical records. For instance, Resident #3, who required moderate assistance with bed mobility and was totally dependent for transfers and toileting, was observed with a side rail in the raised position on multiple occasions without a signed consent. Similarly, Resident #9, who was cognitively intact and required supervision for transfers, was also using side rails without documented consent. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), indicated a lack of awareness regarding the requirement for consent for side rail use. The MDS Coordinator mentioned that therapy evaluates residents for safety and need for side rails, and the information is then passed to the DON to obtain a signed form. However, the DON was unaware that consents were required, and the administrator believed consents should be collected upon admission. This lack of awareness and failure to follow the facility's policy resulted in the deficiency of not obtaining informed consent for the use of side rails for the sampled residents.
Failure to Complete CNA Training Within Required Timeframe
Penalty
Summary
The facility failed to ensure that ten out of ten nurse aides completed the required nurse aide training program within four months of their employment. The facility's policy, dated May 2019, mandates that nurse aides must be certified within 120 days of employment. However, a review of the facility's active employee list revealed that all ten sampled nurse aides, hired between January 2023 and August 2023, were still listed as Certified Nurse Aide (CNA) in training, exceeding the four-month requirement. Interviews with the nurse aides and the Director of Nursing (DON) highlighted issues such as the distance to testing centers and the rapid filling of nearby testing sites as reasons for the delay in completing the training. The Director of Nursing acknowledged the struggle to complete CNA training due to logistical challenges, and the administrator confirmed awareness of the issue, citing filled testing sites as a barrier. Despite offering transportation to alternate testing sites, the problem persisted. Nurse aides expressed frustration over the delays, with one aide mentioning a change of ownership and test center problems as contributing factors. The facility census at the time was 37, and the deficiency was identified through interviews and record reviews conducted by surveyors.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure proper monitoring and documentation of psychotropic and antipsychotic medications for several residents, leading to deficiencies in care. Specifically, five out of seven sampled residents were not monitored for adverse reactions or the efficacy of their medications. Additionally, three of these residents did not have an appropriate diagnosis documented for the use of certain medications. This lack of monitoring and documentation is contrary to the facility's policy, which requires staff to gather and document information about a resident's behavior, mood, and medical condition to justify the use of such medications. Resident #1, who was cognitively intact and diagnosed with depression, was prescribed multiple medications, including Citalopram, Mirtazepine, Seroquel, and Trazodone. However, there was no documentation in the medical record indicating that staff monitored the effectiveness or side effects of these medications. Similarly, Resident #9, who was also cognitively intact and diagnosed with stroke, dementia, and anxiety, was prescribed a range of medications, including Lithium, Abilify, Buspirone, Cymbalta, Lorazepam, and Trazodone, without documentation of monitoring for effectiveness or side effects. The report also highlights the case of Resident #143, who was severely cognitively impaired and received multiple medications, including Clonazepam, Hydroxyzine, Seroquel, and Trazodone, without an appropriate diagnosis or care plan direction for their use. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed a lack of awareness and adherence to the facility's policy on medication monitoring and documentation. The staff acknowledged that non-pharmacological interventions should be tried before medication use and that appropriate diagnoses should be documented for all medications, not just antipsychotics.
Non-compliance with CNA Training Payment Regulations
Penalty
Summary
The facility failed to comply with federal, state, and local laws and professional standards by not providing financial payment for Certified Nurse Aid (CNA) training and certification expenses for two Nurse Aides (NAs) out of two sampled staff. The Missouri Department of Health and Senior Services On Site Visit Evaluation Instrument for Nurse Aid Training form indicated that the facility charged NAs $850.00 through paycheck deductions to complete a CNA training course and certification test. Additionally, the facility's Sponsorship Plan Reimbursement Agreement required NA staff to sign an agreement to pay for half of the cost of CNA training through payroll deduction. Interviews with the NAs revealed that they were informed upon application that they would be required to pay for CNA training and certification, with payments deducted from their paychecks. One NA mentioned not being reimbursed by the facility and not yet being a CNA. The Director of Nursing acknowledged awareness of the charges for training, noting that under previous ownership, the facility paid for the training and was later refunded by the state. The administrator confirmed the practice of charging NAs for training and certification costs as mandated by the new facility owners.
Failure to Document Pneumococcal Vaccine Administration or Refusal
Penalty
Summary
The facility staff failed to document the administration or refusal of the pneumococcal vaccine for three residents out of a sample of seven, despite having a policy in place since August 2016. This policy mandates that residents be assessed for vaccine eligibility upon admission and offered the vaccine within thirty days unless contraindicated or previously vaccinated. Documentation should include the date of administration or refusal, along with specific details if the vaccine is given. However, the medical records for the three residents, aged 88, 81, and 73, did not contain any documentation regarding the receipt or refusal of the vaccine. Interviews with the Director of Nursing (DON) and the care plan nurse revealed challenges in maintaining accurate vaccine records. The DON acknowledged difficulties in keeping up with vaccine documentation and was unsure about the status of the mentioned residents. The care plan nurse indicated that obtaining vaccine information from hospitals during the admission process can be challenging, often requiring multiple follow-ups. Despite these efforts, the necessary documentation was not found in the residents' medical records, indicating a lapse in following the established policy.
Inconsistent Documentation of Residents' Code Status
Penalty
Summary
The facility staff failed to consistently document the code status of residents, specifically for two residents out of a sample of four. Resident #39 was admitted with a Full Code status documented in the nurse's progress note, Physician Order Sheet, and Baseline Care Plan. However, an Outside the Hospital Do Not Resuscitate (OHDNR) form, signed by the resident's guardian and attending physician, indicated a DNR status. The Director of Nursing acknowledged that the DNR orders were not entered into the system, which was an oversight after the forms were signed. Resident #143 was assessed with severe cognitive impairment and had conflicting documentation regarding their code status. The Admission MDS and Physician Order Sheet indicated a Full Code status, while the baseline care plan showed a Do Not Resuscitate status. The comprehensive care plan lacked any direction for advanced directives. The Social Service Designee was unaware of this discrepancy but believed the resident was a DNR. Interviews with staff revealed that the charge nurse and social services were responsible for entering and verifying code status, but inconsistencies in the process led to discrepancies in the residents' medical records.
Failure to Provide Adequate Hemodialysis Care
Penalty
Summary
The facility staff failed to provide adequate care and services for a resident requiring hemodialysis. The deficiency involved the lack of ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments. Additionally, there was a failure in communication and collaboration with the dialysis clinic. The facility's policy on End-Stage Renal Disease did not include directions for pre and post-dialysis assessments or collaboration with the dialysis clinic. The resident's medical records, including the Admission Minimum Data Set (MDS), Physician's Order Sheets (POS), care plan, and Treatment Administration Record (TAR), lacked documentation of hemodialysis treatments and necessary assessments. Interviews with facility staff, including an LPN, the MDS Coordinator, the Director of Nursing (DON), and the administrator, revealed a lack of clarity and responsibility regarding the resident's hemodialysis care. The MDS Coordinator admitted to an oversight in listing hemodialysis on the MDS and care plan. The DON and administrator acknowledged the absence of pre and post-dialysis assessments and communication with the dialysis clinic, attributing the responsibility to the nursing staff. The deficiency highlights a systemic issue in the facility's processes for managing residents requiring hemodialysis.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bluffs, The | 0.8 mi | ★★★★★ | 18 | 0 |
| Lenoir Health Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Neighborhoods Rehabilitation And Skilled Nursing B | 1 mi | ★★★★★ | 4 | 2 |
| South Hampton Place | 1.9 mi | ★★★★★ | 9 | 0 |
| Columbia Post Acute | 3.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.